Whatever would our wallets do without the SI joint?

[deleted993114]

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I have patients sent to me on a daily basis with the diagnosis of "sacroillitis". I know that it exists, but it is certainly not as pervasive as referring docs seem to think. As a matter of fact, I would offer that the majority of those patients with that diagnosis simply have a referred, sclerotomal distribution of pain from the back.

Nonetheless, the poor SI joint tends to get injected, sclerosed, fried, and fused all too often. Have others seen a bunch of patients with failed SI injections or procedures where the practitioner just kept on beating on the poor joint?

 

[Ducttape]

I hypothesize that it is infinitely safer to beat up on the poor SI joint than to beat up on the poor epidural space...

 

[cowboydoc]

I hypothesize that it is infinitely safer to beat up on the poor SI joint than to beat up on the poor epidural space...

Or the pedicles with screws.

 

[GlowInTheDark]

Or the pedicles with screws.

then unscrewing...and rescrewing...and unscrewing...and rescrewing...

 

[kstarm]

I would say that I have the opposite issue where I get patients referred for epidurals frequently that have limited to no findings on their MRI and have a number of features of SI joint pain. "Patient has sciatica" Usually they opt for the SI joint injection and do well.

 

[callmeanesthesia]

I see it both over and under diagnosed. I get some referrals for SI joint that clearly are lumbar, but also referrals where the lumbar has been treated extensively, with a benign MRI, and clear SI joint provocative maneuvers. Lots of SI joint pain in the patients fused down to the sacrum. There is a surgeon locally who likes to do the iFuse system. I guess it’s a biased sample though as I only see the patients who are still having pain.

 

[deleted131481]

I tend to get referrals for 'ESI of the sacroiliac joint' which I find technically difficult.

 

[deleted993114]

I see it both over and under diagnosed. I get some referrals for SI joint that clearly are lumbar, but also referrals where the lumbar has been treated extensively, with a benign MRI, and clear SI joint provocative maneuvers. Lots of SI joint pain in the patients fused down to the sacrum. There is a surgeon locally who likes to do the iFuse system. I guess it’s a biased sample though as I only see the patients who are still having pain.

Certainly in those patients fused down to L5/S1, women who have recently delivered, AS patients, and rheumatoids have a higher incidence of SI pain. I certainly agree that it is a real pathological entity, but MOST of the patients I see with that diagnosis simply have a referred pattern of pain from the lumbar spine.

Most practitioners rely upon "The Fortin Finger Test" and make a diagnosis. However, of the seven physical exam tests, none have any decent specificity, thus the physical exam is not of high value for that diagnosis. All the tests are usually for demonstration purposes for students. Of course, you are doing a FABER test anyway to check hips, so that is a normal part of an exam.

 

[SommeRiver]

Certainly in those patients fused down to L5/S1, women who have recently delivered, AS patients, and rheumatoids have a higher incidence of SI pain. I certainly agree that it is a real pathological entity, but MOST of the patients I see with that diagnosis simply have a referred pattern of pain from the lumbar spine.

Most practitioners rely upon "The Fortin Finger Test" and make a diagnosis. However, of the seven physical exam tests, none have any decent specificity, thus the physical exam is not of high value for that diagnosis. All the tests are usually for demonstration purposes for students. Of course, you are doing a FABER test anyway to check hips, so that is a normal part of an exam.

In my clinic, I will inject the SIJ if there are at least 4 positive exam maneuvers.

 

[bedrock]

In my clinic, I will inject the SIJ if there are at least 4 positive exam maneuvers.

I don’t have the reference on me right now (on phone) but there was a good study demonstrating the predictive value of 3 positive SIJ exam tests.

So requiring 4 may be overkill.

 

[SommeRiver]

Fortin finger
Tender to palpation
FABER
Gaenslen

Those are the 4 I hit on pts who get better with SIJ injections. I will inject with 3 if the pt has risk factors - Female. Fusion. Smoker. Autoimmune dz. EtOH abuse. If fibro they get no injxn bc fibro ALWAYS hurts at the SIJ if you're female.

 

[pmrmd]

A recent review in Pain Medicine highlighted the futility of the usual exam maneuvers to make diagnosis. A bit of history and a bit of touching and confirmation with IA anesthetic.

 

[wendalltwolf]

For a second I thought the title of this thread was talking about people who keep a fat enough wallet in their back pocket to cause unilateral SI joint pain...

 

[joshmir]

I wonder if palpation exam under Flouro, great response to SIJ belt, great but temporary response to a good chiro getting a real pop in the SIJ, would have any useful specificity